COVID-19 has revealed many vulnerabilities in our societal structure. One particular vulnerability is the risk inherent in our use of congregate institutions to house and treat people. This includes the risks of inpatient psychiatric facilities.
Inadvertently, the pandemic has surfaced critical questions that we should seek to answer even when the virus is under control:
- What is the right balance of risk to benefit for inpatient psychiatry?
- Could community-based alternatives provide better value to patients and society?
There have been numerous COVID-19 outbreaks at inpatient psychiatric facilities across the country. Treatment is provided in a congregate setting. Staff and patients come and go from the outside. These are the central risks, similar to those of nursing homes, shelters, jails, and prisons.
In response, local and state governments have been decarcerating their jails and prisons. Currently, however, there exists no clear guidance on how community- and hospital-based providers should evaluate the risks of inpatient psychiatry during COVID-19 and beyond.
What are the immediate needs in psychiatric facilities?
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Detailed guidance for hospitals on how to implement procedures for sanitation, social distancing, testing, and patients’ rights.
Accountability bodies should provide hospitals with detailed guidance. This guidance should cover procedures for sanitation, testing of staff and patients, and discharge planning. It should also help management improve social distancing in a setting where close physical contact can easily occur (e.g., shared rooms, group activities). And hospitals need protocols for how to maintain patients’ rights during the pandemic.
Given COVID-19 concerns, clinicians might need to discharge patients earlier than they would otherwise. There will also be situations in which positive-tested patients are ready for discharge but do not have a place to go to self-isolate. Clinicians should balance these considerations with patients’ rights. This includes the right to receive care in the least restrictive treatment environment.
Clinicians will also, unfortunately, need to consider reimbursement. Massachusetts, for example, is allowing psychiatric facilities to bill its Medicaid program for keeping a patient longer than needed if the patient cannot be safely discharged due to COVID-19.
Restricting visitation can also impede patients’ rights. Patients are particularly vulnerable to harm and abuse in inpatient psychiatric care settings. Visitation is beneficial for patients and also allows for external accountability. Indeed, it provides an opportunity for patients to connect not only with family and friends, but also legal counsel. In Massachusetts, there has been particular concern regarding patients’ right to the outdoors being limited due to the threat of COVID-19. Patients have this right in Massachusetts, but it does not exist in all states.
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Detailed guidance on how community- and hospital-based providers are to balance the risks when making decisions to refer patients to inpatient services
The risk of contracting COVID-19 is not the only factor that alters the risk-benefit calculation during this pandemic. Psychiatric facilities have to consider how new COVID-related policies might undermine therapeutic benefits to the patient. Not only might visitation and access to the outdoors be restricted, but some hospitals might be inappropriately isolating patients and reducing or stopping beneficial group therapies. Patients might also respond negatively to staff wearing facemasks and using other protective equipment. All of these factors could prevent optimal delivery of clinical interventions or exacerbate symptoms. How should referring providers consider these realities?
The American Psychiatric Association collated guidance from the Department of Health and Human Services and the Food and Drug Administration. The only mention of inpatient psychiatric facilities was whether electroconvulsive therapy was considered an essential procedure or not [PDF]. There was no mention on how to balance the risks and benefits in deciding to refer or admit patients. Similarly, the Substance Abuse and Mental Health Services Administration (SAMHSA) does not mention such risk-based decisions in their guidance [PDF]. This is, however, something where consensus was reached by mental health professionals in China.
Complicating the ability of community- and hospital-based providers to weigh these risks are local policies and regulations. Fear of litigation, professional repercussions, and concern for the wellbeing of patients and others, place providers in an almost impossible situation. Lower-level alternatives (e.g., peer respites, intensive community services) might be difficult to access because of an already overstretched mental health care system, their complete non-existence in some areas, and local social-distancing requirements. Local governments and professional oversight entities should create guidelines for managing risks to patients in these situations.
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Improved data collection and surveillance of COVID-19 cases in inpatient psychiatric care settings
We need greater transparency and standardized reporting from hospitals to a centralized entity. The Centers for Medicare & Medicaid Services (CMS) is now requiring nursing homes to report cases to the Centers for Disease Control and Prevention in order to support real-time surveillance. CMS could similarly extend this requirement to inpatient psychiatric facilities that participate in the Medicare program (the vast majority). Ideally these data could be linkable to patient demographic information, to better understand disparities and equity. However, as described elsewhere, we lack surveillance capacity for inpatient psychiatry. Therefore, a basic system that monitors COVID-19 prevalence would be a big step in the right direction.
The federal government could retain this basic system as a permanent mechanism for data collection and surveillance beyond COVID-19. This mechanism could eventually grow to capture complaints, adverse events, deaths, restraint and seclusion episodes, regulatory violations, and inspection reports.
What do we know about the benefits and risks of inpatient psychiatry, independent of COVID-19?
In order to balance the risks with benefits, we need a way to evaluate what the benefits are. Inpatient psychiatric care lacks a thorough evidence-base for its effectiveness as a mode of treatment. This would be unacceptable for most other types of hospital care. Although rigorous descriptions of harm and risk – including differences by certain patient demographic groups – are still needed, the evidence that exists suggests that risk of iatrogenic harm is considerable (see also here, here, here, here, here, here). The risk for suicide also peaks immediately following discharge from inpatient psychiatric care. Researchers have questioned if some of this risk is attributable to iatrogenic harm rather than a selection effect.
What are the long-term needs in psychiatric facilities?
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Invest in data collection and reporting to monitor quality and safety of inpatient psychiatry, and to support research
Inpatient psychiatry lags far behind the rest of health care in regard to data collection. Lack of data impedes surveillance by government entities as well as external accountability bodies. Lack of data also prevents the research needed in order to better understand risks and benefits. The need to empirically balance risks and benefits of inpatient psychiatric care will continue far beyond this pandemic.
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Support the federal Protection and Advocacy for Individuals with Mental Illness (PAIMI) program
The federal PAIMI program mandates the existence of a Protection and Advocacy (P & A) entity in each state. That entity provides external accountability to both institutional and community-based mental health services. COVID-19 makes clear how necessary it is to have external monitoring entities with the authority to investigate issues related to patients’ rights.
However, P & A entities often have to prioritize what they investigate given limited federal funding. Further, P & A entities do not necessarily have reasonable access to data on complaints. This limits their ability to monitor trends and identify investigatory needs. The federal government should consider increasing funding to the PAIMI program.
Further, the federal government should expand the authority of P & As to access complaints received by state regulatory authorities on at least a quarterly basis. Alternately, states or hospitals could be compelled to submit safety information and complaints to a centralized entity (e.g., SAMHSA), which could then be efficiently shared with P & A entities.
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Invest in community-based services and social supports
What makes evaluating the risks of inpatient psychiatry difficult for many providers is the lack of community-based alternatives. Randomized controlled trials have shown that intensive community alternatives confer similar or greater benefit than inpatient care for certain populations. Other alternatives could be equally useful, including peer respites, home care, and sufficiently funded and staffed Assertive Community Treatment teams (see also here).
Certainly, some psychiatric crises might be averted upstream by addressing social services and social determinants of health. It is likely that demand for mental health services will increase as a result of COVID-19. Our current patchwork of community-based services was not acceptable before, and will certainly challenge us in the years to come.
Build on immediate action
COVID-19 has exposed the vulnerability of congregate settings such as inpatient psychiatric care. It has re-exposed an inadequate community-based service system and surveillance system for inpatient psychiatry. We should take action now – focused on COVID-19 in the short term– and build on these efforts beyond the pandemic. Further, we need to continue to scrutinize the risks of inpatient psychiatry, which can only be done with improved research capacity, a centralized surveillance system, and a willingness to engage in honest dialogue.
